Provider Demographics
NPI:1932460896
Name:ADVANCED WELLNESS AND REHABILITATION PLLC
Entity Type:Organization
Organization Name:ADVANCED WELLNESS AND REHABILITATION PLLC
Other - Org Name:ADVANCED WELLNESS AND REHABILITATION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:S
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-698-4411
Mailing Address - Street 1:10513 SILVERDALE WAY
Mailing Address - Street 2:STE 102
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-9499
Mailing Address - Country:US
Mailing Address - Phone:360-698-4411
Mailing Address - Fax:360-698-6953
Practice Address - Street 1:10513 SILVERDALE WAY
Practice Address - Street 2:STE 102
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-9499
Practice Address - Country:US
Practice Address - Phone:360-698-4411
Practice Address - Fax:360-698-6953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-06
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA025202CH00003462111N00000X
WACH00034705111N00000X
WACH00002820111N00000X
WACH00003462111N00000X
WA60138481171100000X
WAAC00002719171100000X
WAMA00015277174400000X
WAMA60182495174400000X
WA603120987174400000X
WAMA60253849174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8868477Medicare PIN
WAGAB02210Medicare PIN